Plans of Care/Assessment/Education/Outcome Measures
Care Navigator™ provides an increasing array of care plans from common diagnoses, like Heart Failure, COPD, and Diabetes, or care situations like post-surgery or palliative care. This content consists of a series of goals and corresponding tasks created using standard practice guidelines that focus on specific aspects of clinical and non-clinical care. Patients and their caregivers can take an active part in contributing to the care plan by adding desired goals to help improve their quality of life and promote two-way communication and collaboration between them and the rest of the care team.
Assessments are built into Care Navigator™ to help any member of the care coordination team evaluate the status of a patient or their caregiver. They can be conducted with the patient as part of a telephonic care management workflow or they can be delivered directly to the patient as a task for them to complete via their smartphone. Results of these assessments, and their applicable scores, can trigger other tasks and goals, contributing to the customization of the patient’s overall care plan. For example, an identified transportation barrier after assessment can trigger a recurring task for transportation to be set up several days in advance of an upcoming doctor appointment.
While standard assessments have already been integrated into Care Navigator™ (eg. PHQ-2/9), any assessment can be added with corresponding rules and algorithms that trigger changes to the patient’s care plan and tasks for the care coordination team.
Education in all formats are integral to the patient experience with Care Navigator™. Whether in print, video or auditory formats, these key pieces are secured from reputable sources and are delivered to the patient, either, as the result of an algorithm triggered by an assessment that drives specific content, or it can be assigned by a member of the care team after a need has been identified.
Care plans, assessments and educational content can be tracked and trended to demonstrate outcomes like streamline in workflow efficiency within the care team and overall increases in patient satisfaction around their care. Care Navigator™’s Clinical and Implementation staff can work with customers to incorporate these elements to augment any Care Coordination Program.
Any of these features can be configured and/or customized to meet customer needs for care coordination workflows and individual patients.